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Combating national issues through staple fortification

Combating national malnutrition issues through staple

Executive summary

Shortages in adequate and intake have led to a rising opportunity to address these deficiencies, working with food incidence of ‘hidden ’, a phenomenon caused by a chronic lack manufacturers to integrate essential into staple food of essential micronutrients in a person’s . Deficiencies in the products through fortification. fortification of staple and minerals essential for achieving good continue , such as wheat and maize flour, has even been shown to play a to countries across the globe, including developed nations, significant role in increasing productivity at work, and therefore where it has been shown that it is possible to be both and stimulating the growth of a country’s economy.1 It also has the malnourished at the same time. Governments, organizations and potential to help make hidden hunger a problem of the past, enabling non-governmental organizations (NGOs) worldwide now have an millions of individuals worldwide to be healthier and able to thrive.

October 2017

Page 1 Combating national malnutrition issues through staple food fortification

The cost of malnutrition

It is estimated that one third of the world’s population is undernourished, caused by a What is hidden hunger? physical or financial lack of access to a Hidden hunger is a phenomenon where a diet is lacking in essential balanced, healthy and nutritious diet. vitamins and minerals, causing the body to be malnourished. Hidden Inadequate nutrition can have a major, long- hunger is present in both developed and developing countries lasting impact on physical health and worldwide, and its prevalence reflects in part the rise in calorie-rich, development, but also places a heavy burden on societies across the world. yet -poor, diets that do not meet nutritional requirements. This can seriously challenge a country’s economic growth.

Figure 1: Prevalence of hidden hunger worldwide2

Magnitude of hidden hunger: Mild Prevalence of low urinary iodine (%) Moderate Severe 1 10 50 100 Alarmingly high No data

People who do not consume a sufficient potential as a consequence of suboptimal five years of age showed in proportion of micronutrients, particularly in nutritional intake, remain a major public 2012.6 Such conditions can increase the risk utero and as children, are more likely to face health concern in a number of developing of illness, but may also result in delayed cognitive and physical difficulties for the rest countries, including many in sub-Saharan mental and physical development, affecting of their . Conditions such as stunting, and the Middle East.3,4,5 It is estimated school performance and productivity during reflected by a failure to reach linear growth that 162 million children worldwide under the working lives of individuals.

Page 2 Combating national malnutrition issues through staple food fortification

Figure 2: Global map of vitamin E status Figure 3: Global map of deficiency in adults8 in healthy populations7

Indication of status: vitamin D level: Desirable Deficiency > 75 nmol/L >30 micromol/l <12 micromol/l 50-74 nmol/L Inadequate Children up to 12 years 25-49 nmol/L 12-30 micromol/l < 25 nmol/L

Figure 4: Prevalence of in the Middle East9

. .  . . Kingdom of Kingdom Saudi Arabia .

. 

United . Arab Emirates Arab .

Country  .   Elderly . Men  Pregnant women  Women of  childbearing age

Lebanon  Adolescents  Children          Prevelance (%) of vitamin D deciency and insuciency (serum 25(OH)D <50 nmol/L)

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Overweight and malnourished

Changes in global dietary habits now mean that malnutrition is no longer a problem that exclusively affects those in developing countries with limited access to food. Reports estimate Why are micronutrients that there are two billion people worldwide living with hidden hunger, which can occur even important? 10 if a person is consuming a sufficient quantity of food. In fact, hidden hunger can, and often The vitamins and minerals does, arise in overweight or obese individuals in developed, westernized regions consuming found in nutrient-rich foods diets that are high in calories, but poor in , and processed foods. The result is that play an important role in our it is now possible to be both malnourished and overweight at the same time. Indeed, Gross Domestic Product (GDP) growth no longer guarantees an improvement in nutritional status. health and wellbeing. Deficiencies of micronutrients in the diet are linked to a is essential for vision Vitamin D, often known as the range of health concerns, as (particularly night vision), growth and ‘sunshine vitamin’, is a -soluble development, immune function and for essential nutrient, providing a number well as an increased risk of healthy male and female reproductive of health benefits. It is recognized for chronic , such as organs. Being deficient in vitamin A is a its role in absorption, which cardiovascular (CVD), leading cause of blindness, and can helps to support bone health. diabetes and . contribute to high rates of childhood Deficiencies can contribute to 11 mortality and serious birth defects. in children and in Aside from helping to improve the physical 12 adults. Vitamin D also plays an and mental health and development of important role in supporting immune individuals, good nutrition is also considered 13 is a -soluble vitamin function and cardiovascular health. a key trigger in ending the ongoing vicious that plays an important role in the cycle of that traps millions of people function of the brain and nervous in societies across the globe. The 2008 system, as well as the formation of red Vitamin E is an essential fat-soluble , a project that blood cells. are incapable of antioxidant vitamin that is important in brought together a panel of world-leading 15 producing this vitamin, so must draw it supporting heart health. It helps to economists, concluded that improving from sources such as animal products, defend cell membranes from oxidative nutrition was one of the best, most cost- fortified food products and dietary damage or inflammation, which can effective development investments to 14 16 supplements. contribute to CVD. address the major challenges facing the planet today.22 Their forecasts and calculations suggested that: Vitamin C is a water-souble antioxidant that is present in many fruits, vegetables and • Spending US$ 60 million a year on dietary supplements, and helps to support immunity and the regeneration of other micronutrient provision could yield antioxidants, such as vitamin E.17 It can also help to achieve good cardiovascular health.18 benefits in terms of improved health, lower Severe vitamin C deficiencies can cause , which can cause bleeding gums and mortality and increased income pain in the muscles and joints. opportunities worth US$ 1 billion

• An annual investment of US$ 19 million in Folic acid is often recommended during performs a number of vital roles in food fortification could bring US$ 570 to prevent neural tube the body, including the transportation million in similar benefits23 defects and support the health of red of oxygen to body tissues and red blood Investing in good nutrition to address 19 blood cells. Deficiency can contribute cell regeneration. A shortfall of iron is shortfalls in micronutrient intake clearly to tiredness, irritability and one of the most common nutritional presents a significant opportunity to improve loss, while severe deficiencies can deficiencies in the world and can result health and wellbeing, optimize development cause anemia and, if in pregnant in anemia, which leads to fatigue, potential, and support the economic stability 20 21 women, can result in premature birth. shortness of breath and weakness. and growth of countries worldwide.

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What is staple food fortification?

Fortification is one of the most safe, effective staple food fortification is now mandatory, a out mandatory national-scale flour and affordable tools to enhance the movement that started to gain traction in the fortification, and several other countries in the nutritional value of staple food products 1970s and took off in the early 2000s as region, including Jordan and Iran, followed such as wheat, maize (corn), , vegetable more and more countries integrated it into shortly after.25 Wheat flour and maize flour oil and . This process involves adding or their nutrition strategies. One of the earliest fortification has also been compulsory in South replacing essential vitamins and minerals regions to adopt was the Middle East where, Africa since 2003 and, in 2016, the Africa Maize that may have been lost during processing, in 1978, Saudi Arabia was amongst the first Fortification Strategy for 2017-2026 was and has become well recognized for its countries to implement wheat flour created, in an effort to upscale the region’s benefits to . In many countries, fortification.24 By 1996, Oman had also rolled maize flour fortification program.26

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What makes it so successful?

Return on investment Acceptance The impressive uptake of staple food The widespread acceptance of staple food fortification can be owed to the fact it can be fortification can be attributed to a number of implemented without changing the dietary patterns of a population. Nor does it require factors: it is relatively easy to implement and conscious engagement or compliance from individuals – advances in technology mean that it it is cost-effective, meaning that is possible to fortify products, such as rice or flour, without any impact on sensory governments and food manufacturers can characteristics, like appearance and taste. As a result, populations can continue to eat the way quickly see tangible results that help to they have always eaten, which helps to not only tackle challenges in consumer attitudes, but justify the initial investment in machinery. is also very important in developing countries or regions, where there is little freedom of Staple food fortification contributes choice over the food products available. significantly to improving the nutritional status and public health of an entire country, saving millions on healthcare costs each year, and enabling more of the population to be in employment and contribute to the economy. This is as a result of a reduced incidence of chronic illness and cognitive and physical stunting which, in turn, contributes to improved school and work performance and productivity. These factors can impact a person’s livelihood and well- being for the rest of their lives, proving that taking what seems like a relatively small step, can provide a huge social return on investment (ROI) for a nation.

In addition to social ROI, staple food fortification has also been proven to have economic implications, too. The 2012 Copenhagen Consensus found that long-term investments to fight hunger and malnutrition, It is clear that staple food fortification has the potential to play an important role in helping to such as market innovations to tackle hunger improve the nutritional status of the global population. However, it is vital that governments and bundled interventions to reduce and the worldwide play their part in bringing about this change. An important micronutrient malnutrition and the factor in facilitating the success of food fortification initiatives is to ensure that mandated prevalence of stunting, could provide a ROI staple foods are properly monitored and enforced by governments, and complied with by the of up to 30:1.27 Similarly, if the aim to lower food industry. Countries that do not engage with such initiatives risk a significant missed chronic malnutrition by 40% by the year opportunity, as well as a loss of the initial investment made if they fail to maintain the running 2030 is achieved, it is estimated to provide a of fortification programs. Perhaps more importantly, those who are in need will not be able to ROI of 45:1.28 receive the benefits that staple food fortification can provide.

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Types of fortification

Flour fortification Flour – wheat and maize, primarily – is one of the most widely distributed and consumed staple food products. In fact, more than 600 million metric tons of wheat and maize flours are milled annually, and consumed as noodles, breads, , and other flour products worldwide.29 Wheat and maize flour are easily fortified with a wide range of micronutrients, meaning that there is huge potential for flour products to substantially improve global public health.30 This is particularly the case in the Middle East and Africa, which have benefited from support from the public sector, including the World Health Organization (WHO) and NGOs such as Nutrition International (NI).31 In Success story: Jordan fact, there are now 87 countries worldwide Mandatory wheat flour fortification was introduced in Jordan in where it is mandatory to fortify at least one 2002, after the country’s first nationally representative survey industrially milled grain, such as maize on micronutrient status revealed that low micronutrient intake or wheat. Of these, 86 countries fortify wheat was a major public health concern.33 Flour was initially fortified with flour alone, or in combination with other iron and folic acid, although fortification with , and vitamins grains, suggesting that there is significant A, B and D followed shortly after. A follow up survey in 2010 showed that opportunity for the food industry and the roll-out of the program in Jordan had been a huge success, with wheat governments to address global malnutrition flour products now routinely fortified with a wide range of essential vitamins and with this staple food product.32 minerals.34 Continued efforts are essential to support and widen the scope of fortification Micronutrients can be added singly or as initiatives, to improve public health in Jordan. a premix to wheat or maize flour, and it is vital that the flour is well mixed so that the added nutrients are distributed uniformly Success story: Cameroon throughout the product. This is achieved by In Cameroon, officials carried out a national scale survey in adding the nutrients at a rate compatible 2009, to investigate the prevalence of micronutrient deficiencies with the flow of flour along a conveyor in the country’s residents, highlighting the issue as a signficant belt, using adjustable feeders, and can public health concern. In response, a mandatory food fortification also be added when flours from different program was launched nationwide in 2011, which saw wheat flour batches converge. To avoid separation of the fortified with micronutrients, such as iron and vitamin B12. A follow up nutrients from the grain, it is important to study in 2017 revealed an improvement in micronutrient status in women make sure that the particle size and weight of and children, as well as a decrease in the prevalence of maternal anemia – significant these micronutrients are the same, or similar, evidence of the potential that such initiatives hold for improving global public health.35 as that of the flour product.

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Rice fortification Vegetable oils and Rice is the primary staple food Oils and are key components of the human diet across the world, crop of approximately half of and provide energy, access to fat-soluble vitamins (vitamins A, D and the global population.36 It E) and the essential fatty acids that are important for optimal growth provides more than a fifth of and development. The consumption of vegetable oils, such as olive, the world’s food calories and is palm and sunflower, is high throughout the world and continues to a major food product, increase, particularly in developing countries and low socio-economic especially in Asia, where groups. These oils can also be fortified with fat-soluble vitamins to individuals consume around increase their nutritional offering, and become a richer source of 150kg of milled rice per person vitamins A, D and E. per year. However, most of the Liquid vegetable oils can also be converted into solid fats, such as nutritional value of rice is lost during milling of the kernels, meaning margarine. However, the challenge lies in the fact that the vitamin A that it is not a rich source of the essential vitamins and minerals. In fact, and D content is often lost during processing. Technologies now exist hidden hunger is widespread in most countries that consume high levels that facilitate the fortification of margarine with a wider range of of rice; even if its residents are consuming enough to address physical micronutrients, including water-soluble micronutrients such as hunger requirements.37 vitamins C, E, iron and calcium, while also replacing the lost fat- There is clearly a big opportunity for food manufacturers to address soluble vitamin A and D content.39 these micronutrient deficiencies through rice fortification, particularly in Instant noodles countries where rice is a major staple food product, or where wheat While not a traditional staple and maize flour fortification programs are less accessible. There are a food product, the popularity of number of methods that can help boost the nutritional quality of rice. instant noodles has soared in Extrusion, which is the most effective technique, embeds micronutrients recent decades due to their into the rice kernel, meaning that these important vitamins and minerals convenience and affordability. are protected from external influences during washing and cooking. This This is particularly true in some process also maintains the look, feel, taste and behavior of traditional Asian and African countries rice kernels, minimizing any impact on sensory experience. such as Indonesia and Alternatively, rice fortification can be achieved by ‘dusting’ the kernel Cameroon, respectively, and with a micronutrient powder that adheres to the grains, or by the they are now available in over spraying of the surface of ordinary rice grains with a vitamin and 80 countries. However, instant noodles have poor nutritional value mineral mix to form a protective coating.38 The challenge with these and often only offer ‘empty calories’ that fulfill physical hunger needs, techniques, however, is that the rice kernels cannot be washed before without addressing micronutrient requirements. The fortification of cooking, as the micronutrients in the kernel would be lost. instant noodles is an important step towards improving public health Furthermore, in some countries such as the US, questions have been through good nutrition, without the need for significant changes to raised as to whether the substances used are suitable for use on food human diet or national dietary patterns. Numerous micronutrients can products. For this reason, extrusion is typically the preferred choice be incorporated to add value to this product, including vitamins A, C, D for food manufacturers who choose to fortify their rice products. and E, folic acid, niacin and minerals iron, zinc and calcium, via custom-made micronutrient blends. Sugar fortification Although diets high in sugar have come into question over their Bouillon cubes impact on human health, sugar continues to be a widely consumed Bouillon cubes, which can be used in soups and instant noodles, as staple food for millions of individuals around the world. In countries well as being a source of spice in some food products, are also of that have mandated its fortification, sugar has proven to be one of the special importance, particularly in Western Africa. They are most cost-effective and safe food-based interventions to combat and inexpensive to produce and are affordable for populations with low control deficiencies, particularly in vitamin A. Conventional sugar incomes. They can also be easily fortified to become an accessible fortification technology uses vitamin A beadlets that adhere to sugar source of vitamin A, , iron and zinc. crystals with the help of oil.

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Conclusion

Hidden hunger continues to be a major public health concern across characteristics of foods. Improving the population’s nutritional status the globe, and can have a devastating long-term impact on the through staple food fortification can help to facilitate a huge social health, wellbeing and development of individuals, societies and and financial ROI to support the world’s economic growth and nations worldwide. Advances in fortification technology now mean development, as well as the work of NGOs and organizations in both the that it is easier than ever for food manufacturers and millers across private and public sector. It can also play a huge part in addressing the globe to combat malnutrition in developing and developed the challenges presented by poor nutrition, such as cognitive and countries, without impacting dietary patterns or the sensory physical stunting, to improve productivity and public health.

Why DSM? DSM is the world’s leading manufacturer of ingredients for health and nutrition. It has been the pioneering industry partner in the establishment of staple food fortification and remains a trusted leader in this area, through its Nutrition Improvement Program. DSM offers a broad range of high quality and affordable premixes to add to fortified staple food. These can be tailored to meet unique requirements and challenges, allowing DSM to fully support customers’ needs and ambitions and provide key advice and solutions.

For DSM, quality is a way of . Quality for Life™ symbolizes quality, Do you want to update your reliability and traceability. This means that our customers are staple food fortification getting the best ingredients, knowing the source on which they program, or start a new one? ™ depend. Quality for Life means sustainability. It is our commitment Contact DSM on nutrition. to our environment, consumers, our business partners, our people [email protected] and the regulatory framework that governs our operations. for an in-depth discussion.

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References 1. UNICEF, Undernutrition contributes to nearly half of all 14. NHS Choices, B vitamins and folic acid, [website], 2014 28. Copenhagen Consensus, Post-2015 Consensus, [website], 2015 in children under 5 and is widespread in Asia and Africa, [website], http://www.nhs.uk/Conditions/vitamins-minerals/Pages/ http://www.copenhagenconsensus.com/post-2015-consensus. 2017 https://data.unicef.org/topic/nutrition/malnutrition/. Vitamin-B.aspx. 29. WHO, FAO, UNICEF, GAIN, MI, & FFI. Recommendations on 2. S. Muthayya et al., ‘The global hidden hunger indices and maps: 15. U.S. Institute of . ‘Dietary Reference Intakes for wheat and maize flour fortification. Meeting Report: Interim an advocacy tool for action’, PLoS ONE, vol. 8, no. 6, p. 1-12. Vitamin C, Vitamin E, Selenium, and Carotenoids’ [website] Consensus Statement. Geneva, World Health Organization, https://www. nap.edu/catalog/9810/dietary-reference- 2009 [website] http://www.who.int/nutrition/publications/ 3. World Health Organization, Child growth indicators and their intakes-for-vitaminc-vitamin-e-selenium-and-carotenoids. micronutrients/wheat_maize_fort.pdf. interpretation, [website], 2016 http://www.who.int/ nutgrowthdb/about/introduction/en/index2.html. 16. E. B. Rimm et al., Antioxidants for vascular disease, Med Clin 30. Food Fortification Initiative, Global Progress, [website], 2017 North Am, 2000, vol. 84, issue 1, p. 239-249. http://ffinetwork.org/global_progress/index.php. 4. Global Nutrition Report, From promise to impact; ending malnutrition by 2030, [website], 2016 http://ebrary.ifpri.org/utils/ 17. Op. cit. (U.S. Institute of Medicine). 31. WHO/FFI, Joint WHO/Flour Fortification Initiative getfile/collection/p15738coll2/id/130354/filename/130565.pdf. Harmonization workshop for wheat and maize flour 18. A. W. Ashor et al., ‘Effect of vitamin C on endothelial function fortification, [website], 2012 http://applications.emro.who.int/ 5. N. Hwalla et al., ‘The prevalence of micronutrient deficiencies in health and disease: a systematic review and meta-analysis docs/IC_Meet_Rep_2012_EN_14767.pdf. and inadequacies in the Middle East and approaches to of randomised controlled trials’. Atherosclerosis Journal, 2014, interventions’, Nutrients, vol. 9, no. 229, 2017, p. 1-28. vol. 235, no. 1, p. 9 - 20. 32. Op. cit. (Food Fortification Initiative, Global Progress). 6. Op. cit. (UNICEF). 19. K. Bibbins-Domingo et al., ‘Folic Acid Supplementation for 33. Ibid. the Prevention of Neural Tube Defects’, JAMA, 2017, vol. 317, 7. P. Szabolcs et al., ‘A systematic review of global alpha- no. 2, p. 183. 34. Jordan Ministry of Health, National Micronutrients Survey tocopherol status as assessed by nutritional intake levels and Jordan 2010, [website] http://www.gainhealth.org/wp- blood serum concentrations’, International Journal for vitamin 20. Ibid. content/uploads/2014/05/56.-Jordan-Micronutrient-Survey- and nutrition research, vol. 14, no. 1, 2016, p. 1-21. Report.pdf. 21. CDC Centers for Disease Control and Prevention 8. International Osteoporosis Foundation, Vitamin D status Recommendations to Prevent and Control in the 35. R. Engle-Stone et al.,‘Iron, Zinc, , and Vitamin B-12 around the world, [website], 2017 https://www.iofbonehealth. , Morbidity and Mortality Weekly Report, Status Increased among Women and Children in Yaoundé and org/facts-and-statistics/vitamin-d-studies-map. [website], 1998 https://www.cdc.gov/mmwr/preview/ Douala, Cameroon, 1 Year after Introducing Fortified Wheat mmwrhtml/00051880.html. Flour’, Journal of Nutrition, 2017, vol. 147, no. 7, p. 1420. 9. Op. cit. (N. Hwalla et al.). 22. Copenhagen Consensus, 2008 Copenhagen Consensus, 36. World Health Organization, Fortification of Rice, [website], 10. World Health Organization, WHO and FAO announce Second [website], 2008 http://www.copenhagenconsensus.com/ 2017 http://www.who.int/elena/titles/rice_fortification/en/. International Conference on Nutrition (ICN2), [website], 2014 copenhagen-consensus-ii. http://www.who.int/nutrition/topics/WHO_FAO_ICN2_ 37. Ibid. videos_hiddenhunger/en/. 23. Ibid. 38. Ibid. 11. A. Sommer, ‘ and Its Consequences: A 24. Food Fortification Initiative, Middle East, [website], 2016 Field Guide to Detection and Control. Geneva’: World Health http://ffinetwork.org/regional_activity/middle_east.php. 39. DSM, Fortification Basics, [website], retrieved 21 June 2017 Organization, 1995. https://www.dsm.com/content/dam/dsm/nip/en_US/ 25. Ibid. documents/oils.pdf. 12. C. R. Paterson, ‘Vitamin D deficiency, rickets and ’, Reference Module in Biomedical sciences, 2017. 26. Food Fortification Initiative, Africa, [website], 2017 http:// ffinetwork.org/regional_activity/africa.php. 13. Vitamin D council, What is vitamin D? [website], 2011 https://www.vitamindcouncil.org/about-vitamin-d/what-is- 27. Copenhagen Consensus, 2012 Copenhagen Consensus, vitamin-d/. [website], 2012 http://www.copenhagenconsensus.com/ copenhagen-consensus-iii.

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